The client at 30 weeks' gestation is admitted with painless late vaginal bleeding. The nurse understands that expectant management includes:
1. Limiting vaginal exams to only one per 24-hour period.
2. Evaluating the fetal heart rate with an internal monitor.
3. Monitoring for blood loss, pain, and uterine contractibility.
4. Assessing blood pressure every two hours.
3
Rationale:
1. Vaginal exams are contraindicated because the exam can stimulate bleeding.
2. Fetal heart rate monitoring will be done with an external fetal monitor. The placenta is covering the cervical os, and therefore the fetal scalp cannot be accessed to apply an internal monitor.
3. Blood loss, pain, and uterine contractibility need to be assessed for patient comfort and safety.
4. Blood pressure measurements every two hours are unnecessary. They can be done on a routine basis or p.r.n.
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a. Is the patient's muscle strength equal in both arms? b. Is ptosis or facial droop present? c. Does the patient appropriately respond to questions? d. Are the pupils equal in reaction and size?
A planned quasi-experimental study using a nonequivalent control group design has several extraneous variables that threaten its internal validity. The nurse researcher's actions should be based on which understanding?
a. The results of the study will not be statistically significant. b. The random assignment of subjects to groups will nullify the intervening variables. c. The study should be strengthened by controlling intervening variables. d. Because observation rather than causation is the purpose of the study, no action is necessary.
Select the normal finding of an examination of the tympanic membrane
1. The membrane flutters when the client holds the nose and swallows. 2. The short process of the malleus is not visible. 3. The color is red. 4. The membrane bulges.
The pediatric nurse watches while a 5-year-old hospitalized patient appears to withdraw from the environment and becomes apathetic to his care. The nurse knows that this patient is in the phase known as:
A) anger. B) protest. C) despair. D) detachment.